What Every Surgeon Should Know About Head and Neck

Surgery

David P Goldstein MD FRCSCDavid P Goldstein MD FRCSCOtolaryngology-Head & Neck SurgeryOtolaryngology-Head & Neck Surgery

Surgical OncologySurgical OncologyUniversity Health Network University Health Network David.goldstein@uhn.on.caDavid.goldstein@uhn.on.ca

ObjectivesObjectives

Focus on approach to evaluation and Focus on approach to evaluation and management of a neck mass and Parotid management of a neck mass and Parotid massesmasses

Briefly highlight key issues in diagnosis & Briefly highlight key issues in diagnosis & management of following types of neck massmanagement of following types of neck mass Congenital disordersCongenital disorders

thyroglossal duct and branchial cleft cyst thyroglossal duct and branchial cleft cyst Salivary gland masses Salivary gland masses Carotid body tumor Carotid body tumor Squamous cell carcinomaSquamous cell carcinoma

Differential Diagnosis Differential Diagnosis

Congenital Congenital Thyroglossal duct cyst Thyroglossal duct cyst Branchial cleft cystBranchial cleft cyst LymphangiomaLymphangioma

Inflammatory Inflammatory Infectious Infectious Non-infectiousNon-infectious

NeoplasticNeoplastic Primary malignanciesPrimary malignancies Metastases to nodesMetastases to nodes

Approach to the Differential Approach to the Differential Diagnosis of Neck Masses Diagnosis of Neck Masses

Age Age Location, Location, LocationLocation, Location, Location Duration of symptoms Duration of symptoms Risk factorsRisk factors Contents of neck mass Contents of neck mass

Differential DiagnosisDifferential Diagnosis

Age is a major determinant Age is a major determinant < 20 years – < 20 years – C C I I N N 20 – 40 years - 20 – 40 years - II CC NN > 40 years -> 40 years - NN II CC

C= congenital

I= inflammatory

N= neoplastic

LocationLocation

Anterior Triangle Anterior Triangle Anterior- midlineAnterior- midline Posterior- SCMPosterior- SCM Inferior- clavicle Inferior- clavicle Superior- mandibleSuperior- mandible

Posterior Triangle Posterior Triangle Anterior- post border of Anterior- post border of

SCMSCM Posterior- trapezius Posterior- trapezius Superior- junction of Superior- junction of

SCM & trapeziusSCM & trapezius Inferior- clavicleInferior- clavicle

Midline Midline CongenitalCongenital

Thyroglossal duct cyst Thyroglossal duct cyst DermoidDermoid

Lateral Neck/Ant Lateral Neck/Ant ΔΔ CongenitalCongenital

Branchial cleft cystBranchial cleft cyst Thymic cystThymic cyst

Posterior Neck ΔΔ vascular/Lymphatic

malformation

Beware of the cystic neck mass in an adult

Differential of Congenital Neck Differential of Congenital Neck Masses Based on LocationMasses Based on Location

Differential Diagnosis of Neoplastic Differential Diagnosis of Neoplastic

Neck Masses based on LocationNeck Masses based on Location Lateral Anterior Lateral Anterior ΔΔ

BenignBenign SchwanomasSchwanomas CBTsCBTs Salivary glandSalivary gland

MalignanciesMalignancies LymphomaLymphoma Nodal metastasisNodal metastasis

UADTUADT SkinSkin

Salivary glandSalivary gland

Midline Anterior Midline Anterior ΔΔ Thyroid Thyroid Larynx cancerLarynx cancer

Direct extension Direct extension MetastasisMetastasis

Posterior Posterior ΔΔ Benign Benign

SchwanomasSchwanomas Malignant Malignant

LymphomaLymphoma Nodal metastasisNodal metastasis

SkinSkin UADTUADT Non H & N Non H & N

Supraclavicular nodes (virchow nodes)

- Classically represents nodal metastases from below the diaphragm

Differential Based on Growth Differential Based on Growth Rate Rate

Slow growing over yearsSlow growing over years Tend to be benign or low grade Tend to be benign or low grade

malignancy malignancy

Rapidly growing neck massesRapidly growing neck masses InfectiousInfectious Malignant – tend to progress over period Malignant – tend to progress over period

of weeks to a few monthsof weeks to a few months

Cystic Neck MassCystic Neck Mass

Congenital Congenital Thyroglossal duct cyst Thyroglossal duct cyst Branchial cleft cystBranchial cleft cyst

Squamous cell cancerSquamous cell cancer Oropharyngeal/ tonsil primary Oropharyngeal/ tonsil primary

Thyroid CancerThyroid Cancer WDTC present with cystic mass WDTC present with cystic mass Classically has dark brown appearanceClassically has dark brown appearance

Tail of parotid masses Tail of parotid masses Warthin’s tumor Warthin’s tumor

Necrotic Neck MassNecrotic Neck Mass

Infectious Infectious Abscess Abscess TuberculosisTuberculosis

Malignant Malignant Squamous cell carcinomaSquamous cell carcinoma

Work-Up of a Neck MassWork-Up of a Neck Mass

History History Physical Physical

Inspection Inspection Palpation Palpation EndoscopyEndoscopy

Diagnostic ImagingDiagnostic Imaging US US CT CT MRIMRI PETPET

Biopsy Biopsy FNAFNA

Other Other Intraoperative Intraoperative

endoscopyendoscopy TB test TB test

HistoryHistory

Duration & growth rate of Duration & growth rate of the massthe mass Malignant lesions tend to Malignant lesions tend to

have progressive growth at have progressive growth at more rapid rate than benign more rapid rate than benign diseasedisease

Location Location Anterior, posterior or midlineAnterior, posterior or midline

Symptoms of inflammation Symptoms of inflammation or infectionor infection Malignant neck masses Malignant neck masses

with necrosis and skin with necrosis and skin involvement may mimic involvement may mimic invasion invasion

Associated symptomsAssociated symptoms Dysphagia, odynophagia, Dysphagia, odynophagia,

otalgia, hoarseness, oral otalgia, hoarseness, oral cavity pain, nasal cavity pain, nasal obstruction, epistaxis obstruction, epistaxis

Suggests UADT Suggests UADT malignancymalignancy

B symptoms – fever, B symptoms – fever, weight loss & night sweatsweight loss & night sweats

Risk factors Risk factors MalignancyMalignancy TB exposureTB exposure Cat scratch Cat scratch

Keep the differential diagnosis in mindKeep the differential diagnosis in mind

History History

Past medical history Past medical history Skin cancerSkin cancer UADT malignancy UADT malignancy SarcoidosisSarcoidosis Fungal infectionFungal infection Dental caries/dental Dental caries/dental

work work Trauma to head and Trauma to head and

neck neck

Family historyFamily history Thyroid cancerThyroid cancer ParagangliomasParagangliomas

History- Risk Factors for History- Risk Factors for MalignancyMalignancy

Tobacco Tobacco Cigarettes, chew, betel nut, cigarCigarettes, chew, betel nut, cigar

Alcohol Alcohol Two together are synergisticTwo together are synergistic

VirusesViruses HPV- oropharynx cancerHPV- oropharynx cancer EBV- nasopharynx cancersEBV- nasopharynx cancers HIV- kaposi’s sarcoma, lymphomaHIV- kaposi’s sarcoma, lymphoma

Immunosupression Immunosupression Transplant patients- Skin cancers, head and neck cancerTransplant patients- Skin cancers, head and neck cancer

OccupationalOccupational Wood working, leather work – paranasal sinus cancerWood working, leather work – paranasal sinus cancer

Risk Factors Cont’dRisk Factors Cont’d

Previous head and neck cancer Previous head and neck cancer Develop second cancer in 18% of patientsDevelop second cancer in 18% of patients

Radiation exposure Radiation exposure Salivary gland cancers, thyroid cancer, head and neck Salivary gland cancers, thyroid cancer, head and neck

sarcomassarcomas

Autoimmune disordersAutoimmune disorders Sjogren’s syndromeSjogren’s syndrome

lymphoma of salivary glandslymphoma of salivary glands Hashimoto’s thyroiditisHashimoto’s thyroiditis

thyroid lymphomathyroid lymphoma

Physical ExaminationPhysical Examination

Neck massNeck mass Location Location SizeSize FirmnessFirmness FixationFixation PulsatilePulsatile Presence of other neck masses or enlarged Presence of other neck masses or enlarged

nodesnodes Movement with tongue protrusion Movement with tongue protrusion Auscultate for bruits if pulsatile Auscultate for bruits if pulsatile

Investigations Investigations

If diagnosis of infectious or inflammatory is If diagnosis of infectious or inflammatory is probable no further work up is necessary and probable no further work up is necessary and appropriate therapy institutedappropriate therapy instituted

Suspected inflammatory disorders may require Suspected inflammatory disorders may require serologic tests serologic tests

If there is any uncertainty in diagnosis or the If there is any uncertainty in diagnosis or the suspected diagnosis is congenital or neoplastic suspected diagnosis is congenital or neoplastic further investigations are requiredfurther investigations are required

When in doubt on your exam – do further When in doubt on your exam – do further investigationsinvestigations

Fine Needle Aspiration Fine Needle Aspiration

• Diagnostic accuracy 70% to 90%

• Simple/ cost effective

• US guidance increases yield & accuracy

• Indication – almost any neck mass• Only relative contraindication to FNA is pulsatile neck Only relative contraindication to FNA is pulsatile neck

mass mass

MOST IMPORTANT TEST- WHEN IN DOUBT PERFORM

Fine Needle Aspiration Fine Needle Aspiration Diagnose most head and neck cancersDiagnose most head and neck cancers

Suspect lymphomaSuspect lymphoma Send for flow cytometrySend for flow cytometry

Cystic neck massCystic neck mass Send washingsSend washings Stain for thyroglobulinStain for thyroglobulin

Still a role for FNA in infectious and inflammatory Still a role for FNA in infectious and inflammatory disorders disorders C & SC & S Presence of pus does not necessarily exclude malignancy Presence of pus does not necessarily exclude malignancy

Squamous cell carcinoma can present with necrotic nodes Squamous cell carcinoma can present with necrotic nodes

Open BiopsyOpen Biopsy

Almost NO role in the initial work-up of a neck Almost NO role in the initial work-up of a neck massmass

ContraindicationsContraindications Pulsatile massesPulsatile masses Parotid masses Parotid masses Suspected malignancies and FNA not been attempted Suspected malignancies and FNA not been attempted

When to do When to do Only after work-up is completed including FNA and Only after work-up is completed including FNA and

diagnosis is still in question diagnosis is still in question FNA is non-diagnostic FNA is non-diagnostic FNA is negative but not in keeping with clinical picture FNA is negative but not in keeping with clinical picture

Open BiopsyOpen Biopsy

Situations in which may be indicated Situations in which may be indicated Lymphoma Lymphoma

FNA is suspicious for lymphoma & further FNA is suspicious for lymphoma & further tissue neededtissue needed

Cystic neck mass Cystic neck mass FNA often inconclusiveFNA often inconclusive Send cyst fluid for cytology Send cyst fluid for cytology Do full work-up prior to open biopsy Do full work-up prior to open biopsy

Imaging and panendoscopy of UADTImaging and panendoscopy of UADT

Open Biopsy Open Biopsy

Incisional vs excisional biopsy Incisional vs excisional biopsy Depends upon size, location and involvement if Depends upon size, location and involvement if

surrounding structures and suspected surrounding structures and suspected pathologypathology

Keep in mind future surgery/neck Keep in mind future surgery/neck dissectiondissection Make the incision in line with potential incision Make the incision in line with potential incision

one would use if further neck surgery is one would use if further neck surgery is required required

Diagnostic Imaging Diagnostic Imaging

Plain films Plain films Limited roleLimited role CXR CXR

Ultrasound/DopplerUltrasound/Doppler Useful noninvasive testUseful noninvasive test VascularityVascularity Solid vs Cystic Solid vs Cystic Sensitive for Sensitive for

adenopathyadenopathy Guided FNAGuided FNA

CT scan & MRI CT scan & MRI Location Location Relation to other Relation to other

structuresstructures Vascularity Vascularity Bone invasionBone invasion MRI for soft tissue MRI for soft tissue

TongueTongue No dental artifactNo dental artifact

MRA/MRVMRA/MRV

MRI MRI Soft tissue Soft tissue No dental artifact No dental artifact

– oral & – oral & oropharynxoropharynx

Bone invasionBone invasion

CT scansCT scans Bone imaging Bone imaging Soft tissue Soft tissue

imagingimaging Dental artifactDental artifact

The Pulsating Neck MassThe Pulsating Neck Mass

Differential DiagnosisDifferential Diagnosis Non-vascular mass situated near carotid artery Non-vascular mass situated near carotid artery Carotid body tumor (paraganglioma)Carotid body tumor (paraganglioma) Carotid artery aneurysmCarotid artery aneurysm

Work-upWork-up Image first Image first

CT with contrast or MRI CT with contrast or MRI If confirmed vascular mass get MRI (MRA & MRV)If confirmed vascular mass get MRI (MRA & MRV)

Avoid FNA but not end of world Avoid FNA but not end of world Incisional biopsy contraindicatedIncisional biopsy contraindicated

Presentation & Presentation & Management of Specific Management of Specific

DiagnosisDiagnosis

Thyroglossal Duct CystThyroglossal Duct Cyst

PresentationPresentation May occur at any age May occur at any age

but most common in but most common in first 2 decades of life first 2 decades of life

Midline at level of hyoid Midline at level of hyoid to thyroid, may be off to thyroid, may be off centre centre

May have hx of infectionMay have hx of infection Classic sign is rising with Classic sign is rising with

tongue extrusiontongue extrusion

DiagnosisDiagnosis History & Physical History & Physical Imaging Imaging

Thyroglossal Duct Cyst Thyroglossal Duct Cyst CautionsCautions

May have papillary ca arising in thyroglossal May have papillary ca arising in thyroglossal duct cyst – rare but I perform FNAduct cyst – rare but I perform FNA

Cystic nodal metastasis from papillary thyroid Cystic nodal metastasis from papillary thyroid ca to delphian node may have similar ca to delphian node may have similar presentation presentation

Treatment Treatment Excision – sistrunk procedure (remove cyst Excision – sistrunk procedure (remove cyst

with track up to tongue base including central with track up to tongue base including central portion of hyoid bone)portion of hyoid bone)

Cosmetic and prevent recurrent infection Cosmetic and prevent recurrent infection

Branchial Cleft CystBranchial Cleft Cyst

Presentation Presentation mass along the anterior mass along the anterior

border of the SCM +/- a border of the SCM +/- a sinus tractsinus tract

Smooth painless slow Smooth painless slow growing unless infected, growing unless infected, may fluctuate in size may fluctuate in size

Treatment Treatment Surgical excision with Surgical excision with

removal of the tract removal of the tract Nerves at risk – CN IX, X, XI Nerves at risk – CN IX, X, XI

XIIXII

Lymphoma• hx of lymphadenopathy – non-resolving• B symptoms – fever, night sweats, weight loss • nodes soft mobile and rubbery, may be very large “bull neck”

Diagnosis• FNA- special solution & adequate amount • Open biopsy- after FNA & lymphoma suspicious clinically

• must be sent fresh • immunophenotyping & flow cytometry

Carotid Body TumorCarotid Body Tumor Carotid body tumors Carotid body tumors

(P(Paraganglioma)araganglioma) Arise from carotid body Arise from carotid body

located at bifurcation located at bifurcation between ICA & ECA between ICA & ECA

Familial in up to 30%Familial in up to 30% Bilateral or multipleBilateral or multiple

DiagnosisDiagnosis Classic imaging Classic imaging

characteristics characteristics Vascular mass splaying Vascular mass splaying

ICA and ECA – lyre’s signICA and ECA – lyre’s sign MRI get salt & pepper MRI get salt & pepper

pattern from the flow pattern from the flow voids voids

Carotid Body TumorCarotid Body Tumor

Treatment Treatment Excision Excision Proximal and distal control of CAProximal and distal control of CA Prepared to bypassPrepared to bypass

ComplicationsComplications Vascular injury Vascular injury StrokeStroke CN injury – CN IX,X,XII CN injury – CN IX,X,XII

Squamous Cell Carcinoma Squamous Cell Carcinoma FNA Dx of SCC

Primary detected No Primary identified; Aka unknown primary

Stage tumor

Treat primary tumor

Treat neck

Imaging to stage the neck disease and help identify the primary source

Panendoscopy in OR with biopsies of tongue base, hypopharynx, nasopharynx and unilateral tonsillectomy

Treat neck and potential primary sites with radiation

Primary Identified

Squamous cell carcinomaSquamous cell carcinomaGeneral Management PrinciplesGeneral Management Principles

Staging Staging Hx, Px (flex scope)Hx, Px (flex scope)

Imaging Imaging CT Head and neck CT Head and neck MR for tongue/tongue base MR for tongue/tongue base Chest CT r/o synchronous primaryChest CT r/o synchronous primary

Panedoscopy/Quadroscopy (EUA under GA)Panedoscopy/Quadroscopy (EUA under GA) Esophagoscopy, Bronchoscopy, Laryngoscopy, +/- Esophagoscopy, Bronchoscopy, Laryngoscopy, +/-

nasopharynxnasopharynx Used for cancers of larynx, hypopharynx and +/- oropharynx Used for cancers of larynx, hypopharynx and +/- oropharynx

Assess the extent of the tumor & surgical resectabiltyAssess the extent of the tumor & surgical resectabilty Obtain biopsy specimens Obtain biopsy specimens Assess for 2Assess for 2ndnd primary primary

Squamous cell carcinomaSquamous cell carcinomaGeneral Management PrinciplesGeneral Management Principles

Treatment OptionsTreatment Options SurgerySurgery RadiationRadiation Chemotherapy Chemotherapy Combination of bothCombination of both

Rads or chemo can be given pre- or post opRads or chemo can be given pre- or post op

Treat the primary site and the cervical Treat the primary site and the cervical lymph nodeslymph nodes Try and treat cervical lymph nodes with the Try and treat cervical lymph nodes with the

same modality of therapy used for the primary same modality of therapy used for the primary site site

How do we decide which How do we decide which treatment to offer treatment to offer

Provide the treatment that will offer the Provide the treatment that will offer the highest survival & control ratehighest survival & control rate based on literaturebased on literature Early stage disease often similar Early stage disease often similar Advanced disease usually combinationAdvanced disease usually combination

QOL and morbidityQOL and morbidity Organ preservation (larynx, hypopharynx)Organ preservation (larynx, hypopharynx) Preserve form and function (oropharynxPreserve form and function (oropharynx Swallowing, speech, cosmesis Swallowing, speech, cosmesis

Goals of TreatmentGoals of Treatment

CureCure Local regional control Local regional control SurvivalSurvival

PalliationPalliation PainPain BleedingBleeding CosmesisCosmesis

Squamous cell carcinomaSquamous cell carcinomaGeneral Management PrinciplesGeneral Management Principles

Oral cavity – surgeryOral cavity – surgery Oropharynx (tonsil, tongue base)- Oropharynx (tonsil, tongue base)-

radiation or chemoradiation radiation or chemoradiation Hypopharynx cancer – radiation or Hypopharynx cancer – radiation or

chemoradiation chemoradiation Larynx- transoral laser surgery for small Larynx- transoral laser surgery for small

tumors, radiation or chemoradiation for tumors, radiation or chemoradiation for most most

Nasopharynx- chemoradiation or radiation Nasopharynx- chemoradiation or radiation

AdenocarcinomaAdenocarcinoma

FNA diagnosis of adenocarcinoma in the FNA diagnosis of adenocarcinoma in the neck – from a distant siteneck – from a distant site Lung, breast, GI, GULung, breast, GI, GU

May require an open biopsy to get more May require an open biopsy to get more tissue for analysis to help identify site tissue for analysis to help identify site

Image chest, abdo, pelvis Image chest, abdo, pelvis Rarely treat the neck b/c metastatic Rarely treat the neck b/c metastatic

disease - palliative therapy to prevent disease - palliative therapy to prevent obstruction of trachea or esophagusobstruction of trachea or esophagus Neck dissection - Only if primary site is Neck dissection - Only if primary site is

controlled and patient is potentially curablecontrolled and patient is potentially curable

Salivary Gland MassesSalivary Gland Masses Major Salivary GlandsMajor Salivary Glands

Parotid- 80% Parotid- 80% (80%benign:20%malignant)(80%benign:20%malignant)

Submandibular 15% (50:50)Submandibular 15% (50:50) Sublingual (40:60)Sublingual (40:60)

Minor Salivary GlandsMinor Salivary Glands Oral cavity/ oropharynxOral cavity/ oropharynx LarynxLarynx Nose & paranasal sinusesNose & paranasal sinuses

ClassificationClassificationNon-Neoplastic

Congenital

Granulomatous

Infectious

Non-infectious Inflammatory

Hemangiomas

Vascular malformations

Lymphatic malformations

1st Branchial cleft cyst

ClassificationClassificationNon-Neoplastic

Congenital

Granulomatous

Infectious

Non-infectious Inflammatory

HIV TBAtypical TBActinomycosisCat-Scratch ToxoplasmosisTularemiaFungal

History & Physical ExamHistory & Physical Exam

Majority of neoplasms (benign or Majority of neoplasms (benign or malignant) present as asymptomatic malignant) present as asymptomatic swellingswelling

Risk factors for malignancyRisk factors for malignancy Majority Majority idiopathicidiopathic Ionizing radiationIonizing radiation Sjogren’s syndrome Sjogren’s syndrome LymphomaLymphoma Skin cancersSkin cancers

Clinical Presentation of Clinical Presentation of CancersCancers

Pain Pain Fixation & invasion of surrounding Fixation & invasion of surrounding

structures i.e. dermis, mandible structures i.e. dermis, mandible TrismusTrismus Facial nerve paralysisFacial nerve paralysis AdenopathyAdenopathy

Facial Nerve Paralysis with a Facial Nerve Paralysis with a Parotid MassParotid Mass

Very rarely occurs with benign Very rarely occurs with benign tumorstumors

12% to 15% parotid malignancies will 12% to 15% parotid malignancies will exhibit facial paralysisexhibit facial paralysis

PathologiesPathologies Adenoid cystic carcinomaAdenoid cystic carcinoma Poorly differentiated carcinomaPoorly differentiated carcinoma SCCSCC

Lab TestsLab Tests Serology if suspect auto-immune process Serology if suspect auto-immune process

Biopsy Biopsy FNA – mainstay FNA – mainstay Open biopsyOpen biopsy

Very rarely indicated for parotid masses: Very rarely indicated for parotid masses: AVOID in most cases AVOID in most cases

Fine Needle AspirationFine Needle Aspiration

Debate about utility of FNA in parotid masses Debate about utility of FNA in parotid masses

Among all H & N sites the parotid gland is Among all H & N sites the parotid gland is associated with the highest FNA inaccuracy ratesassociated with the highest FNA inaccuracy rates

False negative rates higher then false positiveFalse negative rates higher then false positive Sensitivity rates reported can be as low as 38% when Sensitivity rates reported can be as low as 38% when

comes to recognizing malignant nature of parotid comes to recognizing malignant nature of parotid massesmasses

Diagnostic precision is difficult Diagnostic precision is difficult

Determine high vs. low grade tumors is also Determine high vs. low grade tumors is also difficultdifficult

Why do an FNA?Why do an FNA? Accuracy in determining benign from malignant Accuracy in determining benign from malignant

diseasedisease Rates of ~ 90% Rates of ~ 90%

It may help in planning surgery especially It may help in planning surgery especially informed consentinformed consent

It may help in timing of surgery in resource It may help in timing of surgery in resource restricted climaterestricted climate

Change clinical approach in up to 30% of Change clinical approach in up to 30% of patientspatients

Results interpreted in the face of the clinical Results interpreted in the face of the clinical presentation and imagingpresentation and imaging

Diagnostic ImagingDiagnostic Imaging UltrasoundUltrasound

Identifying a massIdentifying a mass Guide FNAGuide FNA Assessing adenopathy Assessing adenopathy

Technitium-99m Scan Technitium-99m Scan Diagnosis of Oncocytoma or Diagnosis of Oncocytoma or

Warthin’s tumor Warthin’s tumor

Sialography Sialography Rarely used Rarely used Little role in routine work-up Little role in routine work-up

of a parotid massof a parotid mass

CT Scan and/or MRICT Scan and/or MRI Main modalities for Main modalities for

imaging parotid imaging parotid neoplasmsneoplasms

Value of Imaging Value of Imaging

Know what you are getting intoKnow what you are getting into ““tip of iceberg” with deep lobe involvementtip of iceberg” with deep lobe involvement Approach Approach

MalignancyMalignancy ResectabilityResectability

Skull baseSkull base Structures requiring resection Structures requiring resection Nodal statusNodal status Facial nerve statusFacial nerve status

Adenoid cystic carcinoma- proximal portionAdenoid cystic carcinoma- proximal portion

Common PathologiesCommon Pathologies

Benign Benign Pleomorphic adenoma Pleomorphic adenoma

Malignant degeneration into carcinoma ex-pleomorphic adenoma in 2-10% of pleomorphic adenomas

Warthin’s tumorWarthin’s tumor 10% bilateral 10% bilateral

Malignant Malignant Mucoepidermoid carcinomaMucoepidermoid carcinoma Adenoid cystic carcinomaAdenoid cystic carcinoma Metastases from skin cancersMetastases from skin cancers

Prognostic Factors with Prognostic Factors with MalignancyMalignancy

HistologyHistology High Grade Malignancies High Grade Malignancies

Older AgeOlder Age Pain at presentationPain at presentation Stage of primary tumor & nodal Stage of primary tumor & nodal

metastasesmetastases Skin invasionSkin invasion Facial nerve dysfunction Facial nerve dysfunction Peri-neural growthPeri-neural growth Positive marginsPositive margins

Malignant Secondary Malignant Secondary NeoplasmsNeoplasms

Direct extensionDirect extensionCutaneous SCC/BCCCutaneous SCC/BCC

Lymphatic metastasesLymphatic metastasesSCCSCCMelanomaMelanoma

Hematogenous Hematogenous MetastasesMetastases

Lung, Kidney, Lung, Kidney, BreastBreast

Direct extensionDirect extension

Metastatic SCCMetastatic SCC

Factors in Decision MakingFactors in Decision Making

Patient factorsPatient factors Age Age Co-morbiditiesCo-morbidities Patient’s concernsPatient’s concerns

Tumor FactorsTumor Factors Histology Histology

Benign vs malignantBenign vs malignant Do you have a diagnosis & how certain are weDo you have a diagnosis & how certain are we

Growth rate Growth rate Risk factors for malignancy Risk factors for malignancy

SurgerySurgery

Majority can be managed with a Majority can be managed with a superficial parotidectomysuperficial parotidectomy

Subtotal parotidectomySubtotal parotidectomy Involvement of deep lobe Involvement of deep lobe

Parotidectomy and transcervical Parotidectomy and transcervical approach to parapharyngeal space approach to parapharyngeal space tumourstumours

Surgical ComplicationsSurgical Complications

Temporary VII nerve paresis=21%Temporary VII nerve paresis=21% Frey’s syndrome=6%Frey’s syndrome=6% Infection=3.6%Infection=3.6% Hematoma=2.7%Hematoma=2.7% Hypertrophic scar=2.4%Hypertrophic scar=2.4% Seroma=0.8%Seroma=0.8% Salivary fistula=0.4%Salivary fistula=0.4%

Indications for Post-Indications for Post-operative Radiotherapyoperative Radiotherapy

High grade cancersHigh grade cancers Recurrent cancersRecurrent cancers Gross or microscopic residual diseaseGross or microscopic residual disease Regional lymph node metastasesRegional lymph node metastases Evidence of locally advanced tumorsEvidence of locally advanced tumors

Thyroid Cancer

Epidemic of Thyroid Cancer

3.6 per 100 000 in 1973 → 8.7 per 100 000 in 2002 represents 2.4 fold increase Davies, L. et al. JAMA 2006;295:2164-2167.

Thyroid Malignancies

Well-Differentiated Carcinomas (80-85%)

Papillary Thyroid Carcinoma (PTC) Follicular Thyroid Carcinoma (FTC)

Medullary Thyroid Carcinoma (5-10%) Anaplastic Thyroid Carcinoma (5-10%) Other malignancies

Lymphomas Distant Metastases

Well-Differentiated Thyroid Carcinoma

Papillary Thyroid CA 75-80% of thyroid

carcinomas Frequently Multifocal Dx on FNA or FS Common Nodal Dz Infrequent Distant Dz Slightly Better

Prognosis

Follicular Thyroid CA 5-10% of all thyroid

carcinomas more aggressive

natural history Solitary Lesion Dx on final path Infrequent Nodal Dz Common Distant Dz Slightly Worse

Prognosis

Medullary Thyroid Carcinoma

C - cell/parafollicular cell origin May be sporadic/nonfamilial (80%) or familial (20%) Familial forms

Medullary thyroid carcinoma alone• MEN 2A (Sipple’s)

MTC, Pheochromcytoma, Hyperparathyroidism• MEN 2B

MTC, Pheochromocytoma, Mucosal Neuromas, Mutations on chromosome 10 for the RET proto-

oncogene Regional lymph node metastases - 50% Distant metastases

Medullary Thyroid Carcinoma

Diagnosis / Screening• Pentagastrin Stimulation with

measurement of calcitonin levels• Ret proto-oncogene screening

Patients who screen positive should undergo early thyroidectomy

Early intervention has resulted in 85% DFS at 15-20 years

Serum calcitonin levels are used as a tumor marker in follow-up

Medullary Thyroid Carcinoma

Treatment• exclude pheochromocytoma• total thyroidectomy• central compartment lymphadenectomy• elective lateral neck dissection for patients

with palpable thyroid disease• therapeutic lateral neck dissection for

patients with palpable neck disease Treatment

• Adjuvant external beam radiation may be used to enhance locoregional control

• The role of chemotherapy remains to be defined

Anaplastic Carcinoma

Rare tumor noted for its rapid growth and nearly uniform lethal nature

Typically develops in a pre-existing well differentiated thyroid carcinoma or a goiter

Poor prognostic factors Advanced age Presence of regional or distant

metastases

Lymphoma of Thyroid Gland

Thyroid Nodules

Approximately 95% of thyroid nodules are benign

4-7% of adults have thyroid nodules Women > men Likelihood of malignancy=5% Malignancy in clinically apparent

nodules=20%

Work-up of Thyroid Nodule

History exposure to ionizing radiation family history of thyroid carcinoma or other

endocrine neoplasms (MEN syndromes)

Physical examination Vocal cord paralysis Fixed and firm Cervical nodes

Investigations

FNA Thyroid U/S TSH

No role for calcitonin, thyroglobulin and thyroid scintigraphy in the initial work-up

FNA (R-A)

Repeatedly Repeatedly Nondiagnostic (R-A)Nondiagnostic (R-A)

Cystic nodule

Solid nodule

ObservatioObservation or n or surgerysurgery

Surgery Surgery strongly strongly consideconsideredred

““Suspicious” Suspicious” for for papillary ca papillary ca or Hurthle or Hurthle cell cell neoplasmneoplasm

SurgerSurgery y (R- A) (R- A)

Indeterminate Indeterminate Cytology Cytology (suspicious, (suspicious, follicular lesion or follicular lesion or neoplasm)neoplasm)

FolliculFollicular ar lesion lesion

Benign Benign

Follow (R-A)

Thyroid scan

HotCold (R-B)

FNA

Risk-group Definitions

AGES A – age (> 40) G – grade E – extent of tumor

extrathyroidal invasion

distant metastases S – size

Other TNM & MACIS

AMES A –

age(M>40,F>50) M – metastases

(distant) E – extent of tumor S – size

Patterns of Failure by Risk GroupsDifferentiated Thyroid Cancer

510

1810

14 17

2

12

34

Low Intermediate High 0

5

10

15

20

25

30

35

40 Local %

Regional %

Distant %

% of pts

13%

26%

50%

Overall %

Treatment

Surgery Post-operative radioactive iodine Post-operative thyroid suppression External beam radiation Post-operative screening

Total vs Less than Total Thyroidectomy

Eliminates all cancer and potential cancer (up to 50% CL)

Allows RAI Allows monitoring with

thyroglobulin Deals with tall cell and

insular Ca & prevents transformation of PTC to anaplastic ca

No compelling evidence for survival advantage

Difficult for RAI Thyroglobulin not

possible Spares the

parathyroids & RLN

Hemi vs Total Thyroidectomy

Low risk disease Controversial R.R decreased with total thyroidectomy Some studies shown no difference

High risk patients Local & regional RR lower in total

thyroidectomy Possibly improved cause specific survival

Complications of Thyroidetcomy

Hypoparathyroidism Temp vs Permanent

Recurrent Laryngeal Nerve Injury Unilat vs bilat Temp vs Perm

Complications

Post-operative hematoma Concern re: airway Prevent obstruction with incomplete

strap muscle reapprox inferiorly Drains do not prevent Management

Airway emergency Open at bedside if patient in resp distress To OR

Neck Management

Clinically negative neck no neck dissection Nodal metastases at presentation

Do not adversely affect survival Does increase risk of locoregional recurrence 80% of nodal metastases are central

compartment Lateral ND only if clinically positive nodes or

identified intra-op Functional neck dissection level II-V Spare IJV, SCM, CN XI, cervical plexus

Radioactive Iodine

Agent - I131

Effect Goal of therapy

Scan Thyroid ablation Therapeutic

Complications Short term Long term

Radioactive Iodine Only useful in cases of well differentiated

thyroid malignancies Results

Overall efficacy difficult to clearly delineate Studies have shown decreased locoregional

recurrences and increased survival in some series

Less efficacious in unresectable disease Pulmonary metastases respond better than

bony metastases

Thyroid Nodules in Pregnancy Uncertainty if nodules in pregnancy are more likely to be

malignant than those found in non-pregnant women No population based studies

Recommendations (C) FNA unless low TSH Malignancy- follow with U/S

Significant growth by 24 wks gestation surgery can be performed at that time point

Remains stable or diagnosed in 2nd half of pregnancy surgery may be performed after delivery

Low TSH if persists after 1st trimester

thyroid scan after pregnancy